Fairness versus Doing the Most Good

Abstract

The Oregon plan is perhaps the most explicit scheme that has yet been devised for rationing medical services. The state of Oregon drew up a list of pairs, each consisting of a particular medical condition together with a particular treatment for it. It arranged these pairs in a ranking from the one it considered most valuable to the one it considered least valuable. It then marked a borderline between those it is prepared to fund through Medicaid and those it is not. The precise criteria Oregon used to draw up its ranking are not very clear. But it is clear that, in a general way, the state had the objective of using its limited medical resources to do the most good possible. It tried to estimate the benefit that each treatment provides, and ranked the more beneficial ones higher than the less beneficial. A treatment that can be expected to extend a patient's life for many years would be ranked higher than one that extends life a short time. Quality of life was also taken into account. A treatment that extends a patient's life and leaves her in good health would be ranked above one that extends a patient's life but leaves her disabled. This feature of the plan led the Bush administration to reject it when it was first proposed. They accused the Oregon plan of discriminating against disabled people because it valued the life of a disabled person less than the life of a healthy person. As it happens, the plan was not guilty of discriminating against the disabled. But it would have been guilty if it had been fully consistent in pursuing its aim of using resources to do the most good. Let me explain why. Valuing a disabled life less than a healthy life is not in itself discriminatory. Many disabled people lead better lives than many healthy people, but the fact is that, other things being equal, a disabled life is generally less good than a healthy one. Suppose a patient faces a choice between two alternative treatments for some disease. Suppose one of the treatments will leave her in good health but the other will leave her disabled. Then the first is without doubt the better treatment, just because a life in good health can be expected to be better than a disabled life. The first treatment would rank higher in Oregon's list. Now take a different case. Suppose two people each have a fatal disease. Each can be treated and each would gain twenty years of life if she were treated. But one of them is already disabled from another cause, so that treating her would restore her to a life with a disability. The other is healthy apart from the particular disease, and treating her would restore her to a healthy life. If, for this reason, the second person were treated and the first were not, without a doubt that would be discrimination on grounds of disability. Discrimination is a type of unfairness. It would be unfair to deny the first person her life on the grounds that she is already suffering from disability. It would be a mistake to deny that treating the able-bodied person can be expected as a general rule to do more good than treating the person with the disability. Treating the able-bodied person will give her a healthy life, and I have already said that as a general rule a healthy life is better than a disabled one. If resources are limited, the state would do more good treating the able-bodied person than the disabled one. Nevertheless, despite this, it would still be unfair to deny treatment to the person with the disability. So this is a case where the aim of using resources to do the most good conflicts with the requirement of fairness. Although Oregon's plan has the aim of using resources to do the most good, it happens not to be unfair and discriminatory in the way I have just described. It ranks condition-treatment pairs rather than treatments for particular individuals, so it cannot discriminate against an individual. Nevertheless, its method is in danger of discriminating less directly, because some diseases may discriminate. …